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03039
DEPARTMENT OF HEALTH
Division of Environmental Health Services
TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641
APPLICATION: TO..CONS�;RUGT, A...WAT.ER , WELL.
PCHD PERMIT #
WELL LOCATION
Street Address
Oscawana Lake
Town/Village/City Tax
Rd Putnam Valley
Grid Number
WELL OWNER
Name
H cha
Address
-Private
0 Public
USE OF WELL
1 - primary
2 - secondary
M*RESIDENTIAL
❑ BUSINESS
❑ INDUSTRIAL
O PUBLIC SUPPLY Q AIR /COND /HEAT PUMP
0 FARM 0 TEST /OBSERVATION
O INSTITUTIONAL ❑ STAND -BY
O ABANDONED
O OTHER (specify
O
AMOUNT OF USE
YIELD SOUGHT
�' gpm /# PEOPLE SERVED /EST. OF DAILY USAGE gal
REASON FOR
DRILLING
ONEW SUPPLY (]PROVIDE ADDITIONAL SUPPLY
XOREPLACE EXISTING SUPPLY ODEEPEN EXISTING WELL
O TEST OBSERVATION
DETAILED
REASON FOR
'DRILLING
WELL TYPE
DRILLED
DRIVEN
DUG GRAVEL
C] OTHER
"IS "WELL SITE SUBJECT TO FLOODING? YES X NO
IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION:
Lot No.
WATER WELL CONTRACTOR: Name Unknown at this time Address:
IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES _ X_NO
NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY
�- DISTANCE - TO -PROPERTY'- FROM NEAREST - WATER MAIN.::.::
LOCATION-SKETCH & SOURCES OF CONTAMINATION PROVIDED
[]ON REAR OF THIS APPLICATION
2q SEPARATE SHEET
10 /1 6/86
(date) (signature
/1'!!�.`n fa�•.y jGI !/ '� -�/ e'•� mJ�i o.� �'✓.� �� S -e .4vcam .+
wSzk6i
TO CONSTRUCT A WATER WELL
This permit to construct one water well as set forth above is granted under the
provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and
provided that within thirty (30) days.of the completion of water well construction,
the applicant shall:
1. Pump the well until the water is clear.
2. Disinfect the well in accordance with the
County Health Department attached to this
3. Submit a Well Completion Report on a form
Health Department.
Date of Issue: Goo 19 S�'6
Date of Expiration: &,, - `3d 19 Y 7
Permit is Non - Transferrable
8/86
requirements of.the Putnam
permit.
provided by the Putnam County
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